https://doi.org/10.15218/ejnm.2021.02 Erbil j. nurs. midwifery, Vol. 4 No. (1), May, 2021 Original Article Knowledge of Shaken Baby Syndrome among Hospital Nurses in Erbil City ABSTRACT INTRODUCTION Shaken baby syndrome (SBS) and pediatric abuse head trauma continue to be the leading causes of child abuse death and the most common causes of mortality and morbidity due to physical child abuse in the United States *1+. SBS is a severe form of child abuse caused by the violent shak- ing of an infant or child *2+. When signifi- cant rotational acceleration-deceleration forces are applied, the brain is susceptible to shearing of the bridging veins in the subdural space, diffuse axonal injury, contusion and oedema. Shaking an infant or small child can cause bleeding into the back of the eyes *3+.and other injuries such as damage to the neck, spine, and eyes *4+. It is dangerous and can cause severe brain damage, blindness, cerebral palsy, mental retardation, behavioural disorders, and impaired motor and cogni- tive skills. Factors that may increase the risk of inflicting shaken baby syndrome Background and objectives: Shaken baby syndrome and pediatric abuse head trauma are the most common causes of mortality and morbidity due to physical child abuse. Nurses have a main role in parents’ education regarding child abuse prevention. This study aimed to assess nurses’ knowledge regarding shaken baby syndrome in Erbil City. Methods: A descriptive study was conducted at postpartum units, the delivery room and the ward at the Maternity Teaching Hospital, and the inpatient and intensive care units at Rapareen Pediatric Teaching Hospital in 2017 in Erbil City. A purposive sample of 50 nurses was recruited to the study. The data collection was performed using a questionnaire for interviewing the study participants, and the data were analyzed using descriptive and in- ferential statistical analysis. Results: The study findings revealed that the majority of the study participants were 19-25 years old and most did not have enough knowledge regarding the signs and symptoms of the shaken baby syndrome (irritability, lethargy, poor feeding breathing problems, uncon- trollable crying, vomiting, bluish skin, changes in sleeping pattern, convulsions or seizures and unresponsiveness). Nurses also had insufficient knowledge about the risk factors of this condition. Only a quarter of nurses knew that domestic violence is a risk factor and less than a quarter of them recognized depression and substance abuse of the caregiver as a risk factor. Regarding knowledge of the complications, the study found that a quarter of nurses knew that brain damage, cerebral palsy and blindness are complications of the shaken baby syndrome. Conclusions: Majority of nurses had poor knowledge about causes, signs, symptoms, risk factors and complications of the shaken baby syndrome. Keywords: Shaken Baby Syndrome; Nurse; Knowledge. Madiha Abass Muhammad; Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Iraq. )Correspondence: madiha.abbas@hmu.edu.krd ) Norhan Zeki Shaker; Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Iraq. Gulala Kream Aziz; Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Iraq. 15 Received: 24/08/2020 Accepted: 02/11/2021 Published: 30/05/2021 mailto:madiha.abbas@hmu.edu.krd?subject=madiha.abbas@hmu.edu.krd https://doi.org/10.15218/ejnm.2021.02 Erbil j. nurs. midwifery, Vol. 4 No. (1), May, 2021 Original Article include unrealistic expectations of babies, young or single parenthood, stress, domes- tic violence, alcohol or substance abuse, unstable family situations, depression, and a history of mistreatment as a child *5+. SBS leads to extreme irritability, lethargy, poor feeding, breathing problems, convulsions, vomiting, and pale or bluish skin. Shaken baby injuries usually occur in children younger than 2 years old, but maybe seen in children up to the age of 5 *6+. The data indicate that 1,000 to 1,500 infants per year are shaken and sustain a head injury. According to the information from the Cen- ter for Disease Control and Prevention in the United States, of the nearly 2,000 chil- dren who die from abuse every year, pedi- atric abusive head trauma, or SBS is re- sponsible for 10-12 percent of those fatali- ties. Research also indicates that there is a strong relationship between poverty and child abuse *2+. Nearly all victims of SBS have serious health consequences, such as brain injury, cerebral palsy, seizures and paralysis, and at least one of every four ba- bies who are violently shaken dies. Most adults who admit to shaking a baby say that they became frustrated and upset when the baby would not stop crying *7+. Child Welfare Information *8+ suggests solving this problem by teaching parents and nurses about the dangers of shaking a baby, as well as ways to cope with the stresses of caring for a child. These educa- tional programmes are very effective in re- ducing the incidence of SBS. A systematic review conducted in New York State rec- ommends that all hospitals should offer new parents the option of viewing a video on SBS, including ways to cope with a cry- ing child. Furthermore, it is reported that in developing countries, SBS is one of the leading causes of death *9+. Currently, there are no statistical data about SBS in Iraq and Erbil City, and no published stud- ies about nurses’ knowledge of SBS, which is one of the reasons for conducting this study. The descriptive study design was used to assess nurses’ knowledge about shaken baby syndrome. This study was carried out from November 2016 to November 2017 at two public hospitals in Erbil City. These hospitals included Maternity and Rapareen Pediatric Teaching Hospitals. Official per- mission to conduct the study was obtained from the Erbil General Directorate of Health and the involved hospitals. A pur- posive research sample consisted of 50 nurses from postpartum units, the delivery room and the ward at the Maternity Teaching Hospital, and the inpatient and intensive care units at Rapareen Pediatric Teaching Hospital in Erbil City. Nurses’ oral informed consent was obtained for partici- pation in the study, after confirmation of confidentiality, anonymity, and partici- pants’ self-determination by the research- er. The researcher constructed a question- naire after an extensive review of relevant literature. The questionnaire included three parts. The first part contained socio- demographic information of nurses (age, gender, level of education, hospital setting, duration of experience in nursing and the current unit, participation in training courses and seminars). The second part assessed nurses’ knowledge regarding shaken baby syndrome and was divided into five domains (definition, carrying baby criteria, signs and symptoms, risk factors, complications). The third part was de- signed to assess the source of nurses’ knowledge about SBS (nursing school, TV, internet, journals, physicians, seminar, workshop and conference). The knowledge of SBS items was rated and scored accord- ing to the two points type scale for all items and scored as 2 and 1 for correct, incorrect answer respectively. After 16 Erbil Journal of Nursing & Midwifery METHODS https://doi.org/10.15218/ejnm.2021.02 Erbil j. nurs. midwifery, Vol. 4 No. (1), May, 2021 Original Article 7.17 ± 5.12 years. Regarding nurses’ pro- fessional background, 8% of nurses partici- pated in a training course related to SBS, and for the highest percentage of nurs- es’ (66%), the source of information was the Internet. Table 2 shows the nurses’ knowledge about the definition of SBS and the questions included the following: SBS is an injury caused by a sudden jerking of the head (1.24 ± 0.43), SBS is abusive head trauma (1.28 ± 0.45), SBS results in a sub- dural hematoma & retinal haemorrhage on the brain’s surface (1.22 ± 0.42). The mean score of nurses’ knowledge regarding the definition of SBS was 1.24. This table shows that most of the nurses answered the questions incorrectly. Table 3 indicates that the mean score of nurses’ knowledge about crying baby was 1.18, showing that the majority of nurses did not know cor- rect answers to the questions in this area. Table 4 shows that the mean score of nurs- es’ knowledge about signs and symptoms of SBS was 1.22. This table also clarifies that the majority of nurses did not have sufficient knowledge of the signs and symptoms of SBS. Table 5 shows that the mean scores of nurses’ knowledge about risk factors and complications of SBS were 1.2 and 1.1 respectively. This table shows that the majority of nurses answered the risk factors and complications of SBS ques- tions incorrectly. Table 6 indicates a statis- tically not significant association between nurses’ level of knowledge about SBS, nurses’ education, and participation in training courses, and a statistically signifi- cant association with duration of experi- ence in nursing. obtaining the average of the mean score of each item, the mean score of each do- main was calculated, followed by a collec- tion of the mean scores of all knowledge items and divided to two levels (poor and fair) for obtaining levels of nurses knowledge about SBS. These levels were considered to be as a following: poor = 0.72 - 0.985, and fair = 0.99 - 1.25.Content validity of the questionnaire was checked initially by a panel of five experts special- ized in maternity and pediatric nursing and medicine, and all experts’ comments re- garding the items of the questionnaire were taken into consideration. A pilot study was conducted on a purposive sam- ple of ten nurses and midwives to deter- mine the reliability of the questionnaire. After two weeks the same nurses were se- lected to assess the same items among nurses from involved hospitals. The partici- pants of the pilot study were included in the main study sample. The reliability of the tool was computed, and the correlation of 0.86 was statistically adequate. The col- lected data were analyzed using the Statis- tical Package for Social Science (SPSS, Ver- sion 20). The descriptive statistical analysis included frequency, percentage, mean, and standard deviation, while chi-square and Fisher exact test were used for inferential analysis. The P-value of ≤ 0.05 was consid- ered significant. Table 1 shows that 44% of participants were within the age group of 19-25 years. The mean score and standard deviation (SD) of their age were 26.54 ± 5.64. The highest percentage (64%) of the sample were nursing institute graduates, and 64% of nurses were working at the Maternity Teaching Hospital (post-partum unit - 12%, delivery room - 12%, inpatient ward - 46%, ICU - 30%. The mean score and standard deviation of nurses’ experience were 17 Erbil Journal of Nursing & Midwifery RESULTS https://doi.org/10.15218/ejnm.2021.02 Erbil j. nurs. midwifery, Vol. 4 No. (1), May, 2021 Original Article 18 Erbil Journal of Nursing & Midwifery Table 1: Demographic data of nurses, sample n=50 Socio-demographic data n=50 *F **% Age 19-25 22 44 26-32 20 40 33-39 8 16 *** ± SD 26.54 ± 5.64 Education level Nursing college graduates 13 26 Nursing institute graduates 32 64 Preparatory nursing school graduates 1 2 Preparatory midwifery school graduates 1 2 Nursing School graduates 3 6 Hospital name Maternity 32 64 Rapareen 18 36 Working Unit Postpartum 6 12 Delivery room 6 12 Ward 23 46 ICU 15 30 Experience years 2-9 38 76 10-17 9 18 18-25 3 6 ± SD 7.17 ± 5.12 Participation in a training course Yes 4 8 No 46 92 Source of infor- mation Internet 33 66 Others 17 34 *Frequency **Percentage *** Mean ± Standard Deviation Table 2: Assessment of nurse’s knowledge about the definition of the shaken baby syn- drome. Nurses’ knowledge about the definition of SBS n=50 Correct F (%) Incorrect F (%) ± SD SBS is an injury caused by a sudden jerking of the head. 12(24) 38(76) 1.24 ± 0.43 SBS is abusive head trauma. 14( 28) 36( 72) 1.28 ± 0.45 SBS results in a subdural hematomas &retinal haemorrhage on the brain’s surface. 11(22) 39(78) 1.22 ± 0.42 Total mean score 1.24 https://doi.org/10.15218/ejnm.2021.02 Erbil j. nurs. midwifery, Vol. 4 No. (1), May, 2021 Original Article 19 Erbil Journal of Nursing & Midwifery Table 3:Assessment of nurses’ knowledge about crying baby criteria Nurses’ knowledge about crying baby criteria n=50 Correct F (%) Incorrect F (%) ± SD Infants cry more often in the late afternoon and evening. 11(22.0) 39(78) 1.22 ± 0.42 Infant crying increases in the first few weeks of life and reaches a peak in the first 2 or 3 months before getting less. 9(18) 41(82) 1.18 ± 0.38 Sometimes a healthy infant cries unexpectedly or without a clear reason. 7(14) 43(86) 1.14 ±0 .35 When an infant cries it is not always a sign that something is wrong. 6(12) 44(88) 1.12 ± 0.33 Sometimes a crying infant can look like she/he is in pain even when they are not. 10(20) 40(80) 1.2 ± 0.40 Sometimes healthy infants can cry for 5 or more hours a day. 10(20) 40(80) 1.2 ± 0.40 It is ok to walk away from a crying infant when his or her crying becomes very frus- trating. 13(26) 37(74) 1.26 ± 0.44 SB is not a good way to help a baby stop crying. 6(12) 44(88) 1.12 ± 0.33 Total mean score 1.18 Table 4: Assessment of nurses’ knowledge about signs and symptoms of the shaken baby syndrome. Signs and symptoms of the shaken baby syndrome n=50 Correct F (%) Incorrect F (%) ± SD Become extremely irritable. 11(22.0) 39(78) 1.22 ± 0.42 Become lethargy. 12(24) 38(76) 1.24 ± 0.43 Become poor feeding. 14( 28) 36( 72) 1.28 ± 0.45 Will complain from breathing problems. 16(32) 34(68) 1.32 ± 0.47 Will complain from uncontrollable crying. 15(30) 35(70) 1.30 ± 046 Will complain from vomiting. 15(30) 35(70) 1.30 ± 046 Become pale or bluish skin. 9(18) 41(82) 1.18 ± 0.38 Will complain from significant changes in sleeping patterns. 9(18) 41(82) 1.18 ± 0.38 Cannot be consoled. 9(18) 41(82) 1.18 ± 0.38 Will complain from convulsions or seizures. 7(14) 43(86) 1.14 ± 0.35 In more severe cases of SBS, the babies may be unresponsive. 7(14) 43(86) 1.14 ± 0.35 Total mean score 1.22 Table 5: Assessment of nurses’ knowledge about risk factors and complication of the shaken baby syn- drome. Risk Factors of SBS n=50 Correct F (%) Incorrect F (%) ± SD Unrealistic expectations of babies 10(20) 40(80) 1.2 ± 0.40 Domestic violence 12(24) 38(76) 1.24 ± 0.43 Depression, substance abuse 11(22.0) 39(78) 1.26 ± 0.44 Family history of SBS. 11(22.0) 39(78) 1.22 ± 0.41 Unstable family situations 8(16) 42(84) 1.16 ± 0.37 Mother’s depression 10(20) 40(80) 1.2 ± 0.40 A history of mistreatment as a child 8(16) 42(84) 1.16 ± 0.37 Total mean score 1.2 Complications of SBS SBS causes severe brain damage 4(8) 46(92) 1.08 ± 0.27 SBS causes cerebral palsy 4(8) 46(92) 1.08 ± 0.27 SBS causes blindness 5(10) 45(90) 1.10 ±0.30 SBS causes behavioural disorders 4(8) 46(92) 1.08 ± 0.27 SBS causes impaired motor and cognitive skills 10(20) 40(80) 1.2 ± 0.40 SBS caused damage to the neck and spine 4(8) 46(92) 1.08 ± 0.27 Total mean score 1.1 https://doi.org/10.15218/ejnm.2021.02 Erbil j. nurs. midwifery, Vol. 4 No. (1), May, 2021 Original Article 20 Erbil Journal of Nursing & Midwifery Figure 1 represents the mean score of nurses’ knowledge about SBS in its fours domains was low. Figure 2 indicates that SBS knowledge of the majority of nurses (88%) was poor and that 12% of study participants had a fair Analysis of demographic characteristics revealed that the highest percentage of nurses were in the age group of 19-25 years and nursing institute graduates. This finding is in contrast to a study car- ried out Brubaker in 2016, which evalu- ated nurses’ knowledge of shaken baby syndrome prevention after exposure to "Period of Purple Crying" Program, and found that lowest percentage of nurses had diploma certificate *10+. The current study indicates that few nurses partici- pated in the training course and the In- ternet was the main source of their in- formation about SBS. As we know the nurse is a primary care provider to in- fants, and a parent educator before the child is discharged from the hospital or when they come for well-child visits and should therefore identify SBS and its consequences, risk factors, signs and symptoms. Testing nurses’ knowledge in the current study was divided into four domains; the first domain evaluated nurses’ knowledge of the definition of SBS. This study reveals that more than two-thirds of nurses responded incor- rectly to SBS definition items, which Table 6: Association between nurse levels of shaken baby syndrome knowledge and edu- cation, age. Nurses criteria Nurses knowledge levels (n=50) Fair* F (%) Poor** F (%) Total F (%) P-value Education level College 10 3 13 0.194 NS*** Institute 29 3 32 Preparatory nursing School 1 0 1 Preparatory Midwifery 1 0 1 School graduate 3 0 3 Duration of Experi- ence years 2-9 35 3 38 0.00 HS**** 10-17 8 1 9 18-25 1 2 3 Participation in train- Yes 2 2 4 0.06 NO 42 4 46 *Poor= 0.72 - 0.98, ** Fair = 0.99 - 1.25, ***NS= Not Significant, **** HS=High Significant 1 1.1 1.2 1.3 1.24 1.22 1.2 1.18 1.1 Definition Signs & Symptoms Risk factors Crying baby critera Complications Fig.1 Distribution of nurses according to mean scores of 4 domains of the shaken baby syndrome knowledge. Fig: 2 Overall levels of nurses’ knowledge about the shaken baby syndrome. DISCUSSION https://doi.org/10.15218/ejnm.2021.02 Erbil j. nurs. midwifery, Vol. 4 No. (1), May, 2021 Original Article 21 Erbil Journal of Nursing & Midwifery reflects nurses’ poor knowledge about SBS. Concerning nurses’ knowledge about crying baby criteria, the current study shows that majority of nurses replied in- correctly to most of crying baby criteria items, with highest percentages only in two items (infant cries is not always a sign that something is wrong, and shaking baby is not a good way to help a baby stop cry- ing), confirming that nurses have knowledge deficit in this regard. Bravo states that every infant who is discharged from a newborn nursery should be sent home with parents who are prepared for neonatal care. Through educational pro- grams, parents can receive positive guide- lines to help them to cope with children who have special needs, need extra atten- tion, or simply cry for long periods *11+, and nurses are responsible for educating of mothers before discharge. Adding to that, SBS often occurs after shaking in re- sponse to crying attacks *12+. This impli- cates the importance of nurses’ knowledge about crying baby. Regarding nurses knowledge about signs and symp- toms of SBS, the finding of the present study reveals that majority of nurses did not know the signs and symptoms of SBS and gave incorrect answers to the ques- tionnaire items (irritable, lethargy, poor feeding, breathing problems, uncontrolla- ble crying, vomiting, bluish skin, changes in sleeping patterns, convulsions or sei- zures and unresponsive). This finding re- veals nurses’ poor information about SBS symptoms when it is expected from the nurses to discover abused and maltreated children in addition to their responsibility in educating parents about SBS prevention and child safety. Regarding nurses’ knowledge about risk factors of SBS, the current study found that about a quarter of nurses know that domestic violence is a risk factor for SBS. This is compatible with the study done in the United States by Steven et al, which mentions that care- takers at risk of abusive behaviour gener- ally have unrealistic expectations of their children and may exhibit a role reversal whereby caretakers expect their needs to be met by the child *13-14+. In the cur- rent study, less than a quarter of nurses recognized that depression and sub- stance abuse of caregiver is a risk factor for SBS of children. This is in agreement with a study, which shows that the most common risk factor for perpetrators, most frequently parents, is the inability to cope with stress, substance abuse, in- fants born to mothers who suffer from depression or consume alcohol during pregnancy *15+. Regarding nurses’ knowledge about complications of SBS, the current study found that about a quarter of nurses know that brain dam- age, cerebral palsy and blindness are complications of SBS. This result is sup- ported by Walls and Castiglia who men- tion that the main complications of SBS involve impaired mental, physical, and sensory development, visual impair- ments, blindness, seizure disorder, devel- opmental delays, motor dysfunction, spasticity, cerebral palsy *16+. Regarding the overall level of nurses’ knowledge of SBS, the majority of nurses had poor knowledge about SBS. According to the discussion and interpre- tation of the study findings, researchers concluded that majority of nurses don’t know the signs and symptoms, risk fac- tors, complications of SBS, and overall, the majority of nurses have poor knowledge level about SBS. Researchers recommend establishing a health educa- tion program for nurses in hospitals to raise awareness of all aspects of SBS. CONCLUSION https://doi.org/10.15218/ejnm.2021.02 Erbil j. nurs. midwifery, Vol. 4 No. (1), May, 2021 Original Article 22 Erbil Journal of Nursing & Midwifery There is no conflict of interest and no fi- nancial support for any of the authors. *1+ Ronald G, Marilyn B, Takeo F, Jocelyn C, Nicole C, and Rollin B. Do educational mate- rials change knowledge and behavior about crying and shaken baby syndrome? A ran- domized controlled trial. Canadian Medical Association Journal, 2014; 180(7): 727-33. *2+ Centers for Disease Control (CDC), what is Shaken Baby Syndrome? www.cdc.gov/ concussion/headsup/sbs/html, 2015. *3+ Christian, C, Block, R. Abusive head trauma in infants and children. Pediatrics, Official Journal of American Academy of Pediatrics, 2009; 123(5), 1409-11. DOI: https:// doi.org/10.1542/peds.2009-0408. *4+ Arabinda K Choudhary, Ramsay Ishak, Thomas T Zacharia, Mark S Dias Affili- ations. Imaging of spinal injury in abusive head trauma: a retrospective study. Pub Med Pediatr Radiol. DOI: 2015 May;45 (5):784. DOI: 10.1007/s00247-015-3335-7. *5+ National MCH Center for Child Death Re- view, Child abuse and neglect fact sheet, http://www.childdeathreview.org/ causesCAN.htm, 2011. *6+ Lee LM, Teutsch SM, Thacker SB, St. Louis ME. (Eds). Principles and practice of public health surveillance. Oxford Scholarship Online; 2010. DOI: 10.1093/acprof:oso/ 9780193572922.001.0001. *7+ Sharyn E Parks, Scott R Kegler, Joseph L An- nest, James A Mercy Characteristics of fatal abusive head trauma among children in the U.S. 2003-2007: An application of the CDC operational case definition to national vital statistics data. Injury Prevention, 2011;18 (3), p.193-9. *8+ Parks Sh, Kegler S, Annest J, Mercy J, Char- acteristics of fatal abusive head trauma among children in the U.S. 2003-2007: An application of the CDC operational case defi- nition to national vital statistics data. 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